Parent/Guardian Name* This field is requiredIf applicable/If not, refill out your name here.

First Name

Last Name

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5

Parent/Guardian Address If different from client's (optional)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

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Please Select

United States

Afghanistan

Albania

Algeria

American Samoa

Andorra

Angola

Anguilla

Antigua and Barbuda

Argentina

Armenia

Aruba

Australia

Austria

Azerbaijan

The Bahamas

Bahrain

Bangladesh

Barbados

Belarus

Belgium

Belize

Benin

Bermuda

Bhutan

Bolivia

Bosnia and Herzegovina

Botswana

Brazil

Brunei

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Canada

Cape Verde

Cayman Islands

Central African Republic

Chad

Chile

China

Christmas Island

Cocos (Keeling) Islands

Colombia

Comoros

Congo

Cook Islands

Costa Rica

Cote d'Ivoire

Croatia

Cuba

Cyprus

Czech Republic

Democratic Republic of the Congo

Denmark

Djibouti

Dominica

Dominican Republic

Ecuador

Egypt

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Falkland Islands

Faroe Islands

Fiji

Finland

France

French Polynesia

Gabon

The Gambia

Georgia

Germany

Ghana

Gibraltar

Greece

Greenland

Grenada

Guadeloupe

Guam

Guatemala

Guernsey

Guinea

Guinea-Bissau

Guyana

Haiti

Honduras

Hong Kong

Hungary

Iceland

India

Indonesia

Iran

Iraq

Ireland

Israel

Italy

Jamaica

Japan

Jersey

Jordan

Kazakhstan

Kenya

Kiribati

North Korea

South Korea

Kosovo

Kuwait

Kyrgyzstan

Laos

Latvia

Lebanon

Lesotho

Liberia

Libya

Liechtenstein

Lithuania

Luxembourg

Macau

Macedonia

Madagascar

Malawi

Malaysia

Maldives

Mali

Malta

Marshall Islands

Martinique

Mauritania

Mauritius

Mayotte

Mexico

Micronesia

Moldova

Monaco

Mongolia

Montenegro

Montserrat

Morocco

Mozambique

Myanmar

Nagorno-Karabakh

Namibia

Nauru

Nepal

Netherlands

Netherlands Antilles

New Caledonia

New Zealand

Nicaragua

Niger

Nigeria

Niue

Norfolk Island

Turkish Republic of Northern Cyprus

Northern Mariana

Norway

Oman

Pakistan

Palau

Palestine

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Pitcairn Islands

Poland

Portugal

Puerto Rico

Qatar

Republic of the Congo

Romania

Russia

Rwanda

Saint Barthelemy

Saint Helena

Saint Kitts and Nevis

Saint Lucia

Saint Martin

Saint Pierre and Miquelon

Saint Vincent and the Grenadines

Samoa

San Marino

Sao Tome and Principe

Saudi Arabia

Senegal

Serbia

Seychelles

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

Somalia

Somaliland

South Africa

South Ossetia

South Sudan

Spain

Sri Lanka

Sudan

Suriname

Svalbard

eSwatini

Sweden

Switzerland

Syria

Taiwan

Tajikistan

Tanzania

Thailand

Timor-Leste

Togo

Tokelau

Tonga

Transnistria Pridnestrovie

Trinidad and Tobago

Tristan da Cunha

Tunisia

Turkey

Turkmenistan

Turks and Caicos Islands

Tuvalu

Uganda

Ukraine

United Arab Emirates

United Kingdom

Uruguay

Uzbekistan

Vanuatu

Vatican City

Venezuela

Vietnam

British Virgin Islands

Isle of Man

US Virgin Islands

Wallis and Futuna

Western Sahara

Yemen

Zambia

Zimbabwe

Other

Country

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6

Parent/Guardian Cell Phone Number* This field is required

Area Code

Phone Number

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7

Parent/Guardian Home Phone NumberIf applicable (optional)

Area Code

Phone Number

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8

Parent/Guardian Email Address* This field is required

example@example.com

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9

Does the client have any siblings? Anyone else at home beyond siblings and parents? Please list names, ages, and relationships.* This field is required

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Does the client have any allergies? If so, please list them here and if any medication is needed for them.* This field is required

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Is the client currently taking any medications? If so, please list the name, dosage, and approximate start date of medication.* This field is required

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12

Please list 3 main reasons why you are pursuing therapy.* This field is required

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Please any problem behaviors that are of concern at this time.* This field is required

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14

Service Agreeement: Please click "YES" if you are in agreement with our terms of service.* This field is requiredIf you have any questions about these terms, please email us at mindy@thebehaviorguru.com

I understand that a consultation does not guarantee treatment. The Behavior Guru LLC strives to provide the best Applied Behavior Analysis therapy. Research has shown that therapeutic relationships between therapist and patient are critical in achieving the best results.Therefore, The Behavior Guru LLC takes client therapist relationships seriously. If we are not a good match, we will provide a referral for another great BCBA.

I understand that all procedures will be discussed with me prior to implementation.

I understand that remote therapy may require me to make changes/do things differently in my home/parenting as they are clinically recommended.

I also understand that in order for me/my child’s therapy to besuccessful I needto be an active participant in therapy. If I fail to do so, The Behavior Guru LLC has the right to terminateservices at any time.

I understand that I have the right to ask questions at any time.

I understand that all me/my child’s records will be kept confidential(see HIPAA Privacy Practices for moreinformation) in a locked storage file and/or a secure online file only accessible to my therapist andme.

I understand that I have the right to ask for records at any time overthe course of therapy. I understand that I must supply a written request for thisto be fulfilled (email suffices).

I agree to pay and understand that services are billed on an hourly basis. At the time of booking an appointment, I will be required to pay for the service. Should the service be canceled, I will be refunded the money entirely (outside of the 24 hour cancellation policy).

I understand that there is a 24 hour policy for late cancellations. If I do not notify the Behavior Guru LLC 24 hours before my session I will be charged the entire session's fee.

I understand that a consultation does not guarantee treatment. The Behavior Guru LLC strives to provide the best Applied Behavior Analysis therapy. Research has shown that therapeutic relationships between therapist and patient are critical in achieving the best results.Therefore, The Behavior Guru LLC takes client therapist relationships seriously. If we are not a good match, we will provide a referral for another great BCBA.

I understand that all procedures will be discussed with me prior to implementation.

I understand that remote therapy may require me to make changes/do things differently in my home/parenting as they are clinically recommended.

I also understand that in order for me/my child’s therapy to besuccessful I needto be an active participant in therapy. If I fail to do so, The Behavior Guru LLC has the right to terminateservices at any time.

I understand that I have the right to ask questions at any time.

I understand that all me/my child’s records will be kept confidential(see HIPAA Privacy Practices for moreinformation) in a locked storage file and/or a secure online file only accessible to my therapist andme.

I understand that I have the right to ask for records at any time overthe course of therapy. I understand that I must supply a written request for thisto be fulfilled (email suffices).

I agree to pay and understand that services are billed on an hourly basis. At the time of booking an appointment, I will be required to pay for the service. Should the service be canceled, I will be refunded the money entirely (outside of the 24 hour cancellation policy).

I understand that there is a 24 hour policy for late cancellations. If I do not notify the Behavior Guru LLC 24 hours before my session I will be charged the entire session's fee.

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15

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16

By signing below you acknowledge receipt of our privacy practices.* This field is required

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